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HomeMy WebLinkAboutMiscellaneous - 30 SUMMIT STREET 4/30/2018 -30 SUMMIT STREET 210/081.0-0060-0000.0 1 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK - CITY North Andover_ _ _ MA DATE 12116115 a PERMIT# JOBSITE ADDRESS 30 Summit St OWNER'S NAME Justine Pangione _ 1 POWNER ADDRESS 30 Summit St —-- _ _ TEL 978-758-0057 _ �;FAX TYPE OR OCCUPANCY TYPE COMMERCIAL i EDUCATIONAL _{ RESIDENTIAL PRINT CLEARLY NEW: _. RENOVATION: _ REPLACEMENT: PLANS SUBMITTED: YES J NO +; FIXTURES 1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 d1314 BATHTUB 1 CROSS CONNECTION DEVICE - DEDICATED SPECIAL WASTE SYSTEM I ; DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM ; DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY 1 1 f 1 - - - -------------- ROOF DRAIN _ SHOWER STALL SERVICE 1 MOP SINK I TOILET - URINAL WASHING MACHINE CONNECTION i WATER HEATER ALL TYPES WATER PIPING _ OTHER i INSURANCE COVERAGE: have a current liabif insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ! NO ._ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY -+1 OTHER TYPE OF INDEMNITY I BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER AGENT _ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME Richard Bowman LICENSE# 13496 SIGNATURE MP -� JP CORPORATION - <# PARTNERSHIP —1# LLC COMPANY NAME Bowman Plumbing Services - _ ADDRESS 6 HORNE STREET CITY Bradford _ 'STATE MA ZIP 01835 _ __; TEL 978-994-6207 FAX F CELL 978-994-6207 , EMAIL BPSMaster@aol.com �� ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINA INS ECT ON OTES _ D� - z ' Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT#___ _ PLAN REVIEW NOTES a x.,, Date.. 441'.... ` 542 ` F aORTh TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING • off,•• ..��:`,'+9 1s`S,CMuS�� 4 This certifies that....... ........................................................ has permission to perform....j - .1 . plumbingin the buildings of.......................................................:.................................... at!E*,� Lic. tit..t�c�[.t.. ........... ............., o h Andover, Mass. Fe ........ No. !. .. ............. ... PL MBING INSPECTOR Check# The Commonwealth of Massachusetts Department of IndustrialAccidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.massgov/dia 11-orkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE(FILED WITH THE PERMMMG AUTHORITY. Applicant Information Please Print Legibly Name(Business/Orgmization/individual):Richard Bowman (Bowman Plumbing Services) Address:6 Home St City/State/Zip:Bradford MA 01835 Phone#:978-994-6207 Are you an employer?Check the appropriate boa: Type of project(required): 1.[]I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.R]I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.F-1 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 E]Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.E]Plumbing repairs or additions 5.rl I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑ p Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. 1 am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy andjob site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Siggature: Date: Phone#:978-994-6207 Official use only. Do not write in this area,to be completed by city or town official, City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. I The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 02-23-15 www.mass.gov/diA Crawford Crawford &Company Crawford &Company 1001 Summit Boulevard Atlanta, GA 30319 Phone: 1-800-221-3509 Fax: 404-300-1215 4/8/2015 Inspector of Buildings c/o Town of North Andover 1600 Osgood St. North Andover, MA 01845 Re: Insured: JOHN SULLIVAN and SUSAN SULLIVAN Claim Number: KCHV91 Policy Number: BCJBBK Our File: 6776-2596176 Date of Loss: 2/22/2015 Type of Loss: Water Damage Location of Loss: 29 SUMMER STREET NORTH ANDOVER, MA 01845 Insurance Company: Mapfre Insurance To Whom It May Concern: Claim has been made involving loss, damage, or destruction of the above captioned property,which may either exceed $1,000 or cause Massachusetts General Laws, Chapter 143, Section 6,to be applicable. If any notice under Massachusetts General Law, Chapter 139, Section 3B is appropriate, please direct it to the attention of the writer. Kindly include a reference to the captioned insured, location, date of loss and claim number. Very truly yours, Keith Davis Claim Representative CC: City/Town Fire Dept, City/Town Health Dept THEWORFOLK DEDHAMGROUP® November 6, 2013 FORM OF NOTICE OF CASUALTY LOSS TO BUILDING UNDER MASS. GEN. LAWS, CH. 139, SEC. 3B Building Commissioner, or Inspector of Buildings c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 Board of Health or Board of Selectmen c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 Fire Department or Arson Squad c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 RE: Our File No.: P1365991 Insured: 30-32 SUMMIT STREET CONDO C/O JAYNE RENNIE Address: 30-32 SUMMIT STREET, NORTH ANDOVER, MA Policy No.: R0631896A Loss Date: 09/26/2013 Loss Type: Building or Other Structure Damage A claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Ch. 143, Sec. 6 to be applicable. If any notice under Mass. Gen. Laws, Ch. 139, Sec. 3B is appropriate, please direct it to my attention and include a reference to the captioned insured, location, policy number, loss date and claim or file number. If no reply is received from your office within ten days, we will assume you have no liens of any type against this property, and the claim will be paid in our customary manner. Sincerely, Linda E. Babineau Property Claim Examiner 1-800-688-1825 x1253 NORFOLK&DEDHAM MUTUAL FIRE INSURANCE CO. 222 Ames Street,P.O.Box 9109,Dedham,MA 02027-9109 DORCHESTER MUTUAL INSURANCE CO. Telephone:(800)688-1825 FITCHBURG MUTUAL INSURANCE CO. p Fax:(781)329-1818 TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING r h» ^ BUILDING PERNIIT NUMBER. U.�J DATE ISSUED: 7- 31-03 3/-03 X SIGNATURE: l � Building Commissioner/inspector of Buildings Date —6F3 SECTION 1-SITE INFORMATION I O 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(so Fronts e ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide R redProvided R red Provided 1.7 Water Supply M.G.L.C.40. 34) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone 0 Municipal ❑ On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT Historic District: Yes No X11 2.1 Owner of Record Name(Print) Address for Service: Signature Telephone 2.2 Owner of Record: Name Print Address for Service: O Z 111 Signature Telephone 90 SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Liceftsed Construction Supervisor: O License Number Wn Address D Expiration Date ic Signature Telephone r 3.2 Registered Home Improvement Contractor Not Applicable ❑ v VIP- CI)AZ Company Name P ,O\Q 3 m Registration Number r Address v {p `Z Expiration Date ^ Signature Telephone Y, i SECTION 4-WORKERS COMPENSATION(1VLG.L C 152 § 25c(6) + Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes.......0 No.......0 SECTION 5 Description of Proposed Work(check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition 0 Accessory Bldg. ❑ Demolition ❑ Other ❑ Specci. P s Brief Description of Proposed Work: n GAN�e cn� SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be - = OFFICIAL USE`"ONLY Completed by permit applicant n I. Building 6® (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a)X(b) 4 Mechanical HVAC 5 Fire Protection © 6 Total. 1+2+3+4+5 f t - r Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner/Authorized Agent of subject property Hereby authorize to act on t My behalf,in all matters relative to work authorized by this building permit application. -Signature of Owner Date i SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION i 1, as rp �.��, � ��; �-, as Owner/Authorized Agent of subject f property Hereby declare that the statements and infonnation on the foregoing application are true and accurate,to the best of my knowledge and belief Print N ne (� Si ature of Owner/A ent Date _ . x , NO.OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 ST2ND 3KD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS i DtIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHRVINEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NA'T'URAL GAS LINE Location _,ZIP No. Date MaRTM TOWN OF NORTH ANDOVER s + = Certificate of Occupancy $ ,ssACMUSEt� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 1 V2,z, )2-,f 16573 —Building lns, e,6 x ✓�ZQ d F � � a atiotls ant Pall r � rc5,ni� cisng ss Pwv Y� r � P.2�1.'+�a�� �,'"�Q3&•� -' ]�' s`.ter^. afsbi22b04 1<EN�t`1ETti CAR {i�j' AA ! . Cenne arew,Jr�\ 6 SalSamwood14 "Ave4" Adm n�str`tnr` -y Billerica,MA o1821 L 77 F 4 a <fd rdsx' oft T � �� r -+ s� t79 a l ? s - �'� e�eg1�t isti5���*�^u a� s'• € � p rtfhs6it2004 �. ,, r fix` KEN�I,ETH CAREI�NRCtJSOOiOM benne Carew,Sr 6 Balsamwood Avea� �` :• MA 01821 Adm►nistra�t Billerica, � +• Vii_ �� � •sem ,dgfs�=/�� zs ��i::% r2;���� 7��� lid Mb-1110'.M All a s y r Yeti Y O h # xp�la 25 2004 f c >f �iy� Bp a r KENNETH CAREW1ClJ��b��6tv1VP � k,iAb .� enne%r Idarew,Jr�\ 6 8alsamwood Ave x R,r Adm�nssti� tl Billerica,MA 01821 � i i t tea: aids -41 ` �� n'�6Y2 )2001 , rt till DBA `. 3 �- KENN TH CARE�7VJR5TOMWibM rjf= t �Zenne Carew,J 6&Itamwood Ave ( fr 8dierica,MA 01821 Adm►n�sat�r,F< NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in properly licensed solid waste disposal facility as defined by MGL Chapter 111, S 150 A. The debris will be disposed of in: i n �- (Location of Facility) Signature of Wt Applicant ' Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector JL V W 11 Vl V l &XNEX v %.•t o No. � O� �-oCHIC L w c�y dower, Mass., �d ADRATED pPa��S S H BOARD OF HEALTH Food/Kitchen Septic System • BUILDING INSPECTOR THIS CERTIFIES THAT ....�.....PERML.,OT .......................................................... ............................ Foundation has permission to erect........................................ buildings on d'.....34..... ............. .... Rough to be occupied as ..................................................................................... Chimney . . . ... . . .. . . . . provided that the person acc g this permit shall in ev respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION STAELECTRICAL INSPECTORRTS Rough Service B ING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det.